Medicare Part D Coverage Determinations, Appeals, and Exceptions

Part D Coverage Determination or Appeals

If your health care provider or pharmacist tells you that we will not cover a prescription drug or charges you more than you think your copay should be, you
or your provider may contact us and ask for a Coverage Determination. The following are examples of when you can ask us for a Coverage Determination:

If there is a limit on the quantity (or dose) of a drug and you disagree with the limit

If there is a requirement that you try another drug before we will pay for the drug you are asking for

If the copay for a drug is higher than expected

If the drug is listed as non-formulary

If you or your provider do not agree with the outcome of the initial Coverage Determination, you or your provider may
appeal
the decision by having your provider request a Coverage Redetermination. This is also called an Appeal.

The process for requesting a Coverage Determination is discussed in more detail in Chapter 9 of your Evidence of Coverage, “What to do if you have a problem or complaint (coverage decisions, Appeals, and complaints).”

How to Request a Coverage Determination or Redetermination (Appeal)

There are 2 ways to request a Coverage Determination or Redetermination (Appeal). Either one of these 2 ways to request a Coverage Determination or Redetermination (Appeal) will be accepted.

1. By Phone

If you call us, we may need to get more information from your prescribing health care provider.

Prior Authorization: Required for some drugs before they will be covered.

Prior Authorization is only needed for certain drugs. If your health plan”s formulary guide indicates that you need a Prior Authorization for a specific drug, your health care provider must submit a prior authorization request form for approval. If the request is not approved, please remember that you
always have the option to purchase the drug at your own expense.

Quantity Limits: Applied to some drugs based on the approved dosing limits established during the FDA approval process. Quantity limits are applied to the number of units dispensed for each prescription.

There are Quantity Limits for some drugs. If the List of Covered Drugs indicates that there is a Quantity Limit for a specific drug, your health care provider must submit a quantity limit exception form for approval. If the request is not approved you have the option to Appeal the decision.

Step Therapy: Requires you to try one or more drugs before coverage of a different drug is provided.

Step Therapy is used for some drugs. If the List of Covered Drugs reflects that Step Therapy is used for a specific drug, your health care provider must submit a step therapy exception form for approval. If the request is not approved, please remember that you always have the option to purchase the drug at your own expense.

If you have already paid for Part D drugs covered by the plan, you can ask our plan to pay you back. Use the form below to request a reimbursement for the plan’s share of the cost of your Part D drugs. See Chapter 7 in your Evidence of Coverage for more information.

CMS Appointment of Representative

You may choose someone to act on your behalf. You may choose someone such as a relative, friend, sponsor, lawyer, or a doctor. A court may also appoint someone.

You and the person you choose must sign, date, and complete a representative statement (see link to form below). A request may also be made in a written letter. If you are legally not of sound mind or are incapacitated, the representative can complete and sign the statement. The representative needs to have
the appropriate legal papers or legal authority to sign for you. If you choose a lawyer, only you need to sign the representative statement.

The representative statement must include your name and Medicare number. You can use Form CMS-1696-U4 (see link to form below) or SSA-1696-U4, Appointment of Representative. You can also find this form at Social Security offices, although it is not required.

SeniorCare Complete and AbilityCare are health plans that contract with both Medicare and the Minnesota Medical Assistance (Medicaid) program to provide benefits of both programs to enrollees. Enrollment in either plan depends on contract renewal.